City of Berkeley WIC Program Screening
The Women, Infants, and Children (WIC) program is a supplemental nutrition program that supports pregnant women, postpartum mothers, infants, and young children to eat well, be active, and stay healthy.

This questionnaire is intended for our staff to learn about you and your family and to see if you qualify for the program. Please take a few minutes to answer the questions below to the best of your ability.

All your responses to this questionnaire will remain confidential and will only be shared with appropriate staff members to assist you.

We look forward to serving you!

City of Berkeley WIC Program Staff
1900 Sixth Street, Berkeley, CA 94710
(510) 981-5360
wicprogram@cityofberkeley.info
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City of Berkeley WIC Program Screening Questionaire
Full Legal Name of Parent/Mom/Dad/Guardian *
Current Home Address *
Is the above address also your mailing address? *
If no, please provide your mailing address in the question below.
Mailing Address
If mailing address is same as home address, put "same as home address."
Email Address *
Phone Number *
Alternative Phone Number
Have you or your child participated in the WIC program in the past year? *
How did you hear about our WIC Program?
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